Bartholin Duct Cyst and Gland Abscess:​​

Office Management
Folashade Omole, MD;​​Riba C. Kelsey, MD, MSCR;​​Kiwita Phillips, MD;​​and Kirstie Cunningham, MD
Morehouse School of Medicine, Atlanta, Georgia

The Bartholin glands, located in the base of the labia minora, have a role in vaginal lubrication. Because
of the presence of other glands, removal of a Bartholin gland does not affect lubrication. Ductal block-
age of these typically pea-sized structures can result in enlargement of the gland and subsequent
development of Bartholin duct cysts or gland abscesses. Two percent of women will develop a cyst
or an abscess in their lifetime, and physicians should be familiar with the range of treatment options.
Bartholin duct cysts and gland abscesses can be treated in the office. The healing and recurrence rates
are similar among fistulization, marsupialization, and silver nitrate and alcohol sclerotherapy. Needle
aspiration and incision and drainage, the two simplest procedures, are not recommended because of
the relatively increased recurrence rate. (Am Fam Physician. 2019;99(12):760-766. Copyright © 2019
American Academy of Family Physicians.)

The Bartholin glands, homologues of the male bulbo- during intercourse.2 Several vulvar lesions mimic Bartholin
urethral glands, are found bilaterally at 4 and 8 o’clock of duct cysts and gland abscesses 1-3,7 (Table 11).
the labia minora and drain through ducts 2.0 to 2.5 cm Abscesses are not always preceded by cysts and occur
long 1,2 (Figure 11). The glands are impalpable and usually three times more often.1,4,8 Single or polymicrobial
pea-sized, rarely exceeding 1 cm.2 The epithelium of the
gland is columnar and the duct is squamous, allowing for
FIGURE 1
the possibility of squamous cell carcinoma or adenocar-
cinoma development.3 During sexual arousal and inter-
course, the Bartholin glands secrete vaginal lubricating
mucus.2,4 Because of the presence of other glands, includ-
ing the Skene glands, removal of a Bartholin gland does not External
affect lubrication.1,2,5 urethral
orifice
Pathology Vestibule
Two percent of women develop a Bartholin duct cyst or
gland abscess in their lifetime, and physicians should be
familiar with the anatomy and range of treatment options.1,3 Duct of
Bartholin
The ducts leading from the Bartholin glands can become gland
obstructed, resulting in formation of cysts and, when
infected, abscesses in the gland.6 Bartholin duct cysts and
gland abscesses are more likely to occur in sexually active
women as a result of ductal obstruction caused by friction
Bartholin gland

CME This clinical content conforms to AAFP criteria for

continuing medical education (CME). See CME Quiz on Anatomy of Bartholin glands.
page 735. Illustration by Marcia Hartsock
Author disclosure:​​​ No relevant financial affiliations. Reprinted with permission from Omole F, Simmons BJ, Hacker Y.
Patient information:​​ A handout on this topic is available at Management of Bartholin’s duct cyst and gland abscess. Am Fam
Physician. 2003;​​68(1):​​135.
https://​family​doctor.org/condition/bartholins-gland-cyst.

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 BARTHOLIN DUCT CYST

opportunistic organisms can cause

TABLE 1 abscesses. Escherichia coli and Staph-
ylococcus aureus are the most com-
Differential Diagnosis of Cystic and Solid Vulvar Lesions mon isolates.6-9 Respiratory organisms
Lesion Location Characteristics such as Streptococcus pneumoniae and
Cystic lesions
Haemophilus influenzae are becom-
Bartholin duct Vestibule Usually unilateral, asymptomatic if small
ing more common, possibly because
cyst of the practice of oral sex.9,10 Sexually
transmitted infections have a role in a
Bartholin Vestibule Usually unilateral, painful, erythematous;​​ minority of cases.1,2,6
gland abscess may be fluctuant
Bartholin gland involution occurs
Cyst of the Labia majora, Soft, compressible;​​peritoneum entrapped by 30 years of age, and enlargement in
canal of Nuck mons pubis within round ligament;​​may mimic inguinal women older than 40 years should raise
hernia suspicion for malignancy, particularly
Epidermal Labia majora Benign, mobile, nontender;​​caused by trauma if the gland is firm, fixed, or irregu-
inclusion cyst (usually) or obstruction of pilosebaceous ducts larly shaped.1 Therefore, biopsy with or
without excision is recommended in
Hidradenoma Between labia Benign, slow-growing, small nodule (2 mm
papilliferum majora and to 3 cm);​​arises from apocrine sweat glands
patients 40 years and older to rule out
labia minora malignancy.1,5,8 Although Bartholin
gland cancers account for only about
Mucous Labia minora, Soft, smaller than 2 cm in diameter, smooth 5% of vulvar carcinomas, early recog-
cyst of the vestibule, peri- surface, superficial location, solitary or mul-
vestibule clitoral area tiple, usually asymptomatic
nition is important because of the risk
of local invasion and metastasis.1,5,11-14
Skene duct Adjacent to Benign, asymptomatic;​​if large, may cause The two most common types of Bar-
cyst urethral meatus urethral obstruction and urinary retention tholin gland carcinomas are squamous
in vestibule
cell carcinoma and adenocarcinoma.
Solid lesions Human papillomavirus, particularly
Acrochordon Labia majora Benign, fleshy, variable size, polypoid in type 16, is associated with the patho-
appearance;​​usually pedunculated but may genesis of squamous cell carcinoma of
be sessile the Bartholin gland.14-16
Angiokeratoma Multicentric Rare, benign, vascular, variable size and
shape, single or multiple;​​associated with Presentation
and aggravated by pregnancy;​​associated Presentation varies with the size and
with Fabry disease depth of the cyst or abscess. Unilat-
Fibroma Labia majora, Firm, asymptomatic;​​ may develop pedicle;​​ eral, medially protruding vulvar swell-
perineal body, may undergo myxomatous degeneration;​​ ing (Figure 2) may be accompanied by
introitus potential for malignancy dyspareunia, vulvar pain, or pain with
Leiomyoma Labia majora Rare;​​solitary, firm;​​arises from smooth
walking or sitting. Fever may also be
muscle present in patients with an abscess.5,7,17

Lipoma Labia majora, Benign, slow-growing, sessile or Office Management

clitoris pedunculated
Of the several available office proce-
Neurofibroma Multicentric Small, fleshy, multiple, polypoid in appear- dures, none has been proven superior
ance;​​associated with von Recklinghausen in terms of healing time or recurrence
disease rate. Although needle aspiration and
Squamous cell Multicentric Related to benign epithelial disease in older incision and drainage are not compli-
carcinoma women and to human papillomavirus infec- cated to perform and have shorter heal-
tion in young women ing time, they confer a considerably
Adapted with permission from Omole F, Simmons BJ, Hacker Y. Management of Bartholin’s
higher risk of lesion recurrence.1,2,5,8,17,18
duct cyst and gland abscess. Am Fam Physician. 2003;​​68(1):​​137. Management is determined by the
cyst size, symptoms, patient’s age,

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 BARTHOLIN DUCT CYST

and history of recurrence.8 Asymptomatic cysts in women

younger than 40 years can be left untreated, whereas larger FIGURE 2
cysts and abscesses may require minor surgical procedures
and excisions.1,5,8,19 Antibiotic treatment of Bartholin duct
cysts and simple gland abscesses is not necessary in the
absence of sexually transmitted infection, urinary tract
infection, or cellulitis.2,8,17,20
Fistulization and marsupialization are the two most
common procedures for Bartholin duct cysts and gland
abscesses.17 Fistulization is the traditional approach for
treating symptomatic cysts or abscesses, although it is not
appropriate for deep cysts.1,8 The introduced foreign body
prevents wound closure, resulting in an epithelialized fis-
tula (i.e., a new outflow tract).17,21,22 Fistulization is achieved
by the placement of a Word catheter or Jacobi ring.17,18
The Word catheter is commercially available, whereas the
Jacobi ring is assembled by the clinician. Patient and cli-
nician satisfaction with the Jacobi ring is higher compared
with the Word catheter.23 The Jacobi ring and the Word
catheter result in good resolution, low recurrence, and
fewer postprocedure complications;​​they are also easy and
inexpensive.19,23
Marsupialization is appropriate for treatment of a pri-
mary or recurrent Bartholin duct cyst or gland abscess. It
creates a new outflow tract after the cyst wall shrinks over
time and reepithelializes.2,5,21
Although no recent studies have compared all types Bartholin gland abscess.
of fistulization with marsupialization, some have com-
pared Word catheter fistulization with marsupialization,
with conflicting results. One study comparing the ease,
TABLE 2
lesion recurrence rate, and cost of Word catheter fistuli-
zation with marsupialization concluded that the Word Preparation for Fistulization,
catheter conferred a higher recurrence rate than marsu- Marsupialization, and Sclerotherapy
pialization, although its placement was easier and less
The labia majora is everted, and the mucosal surface
expensive.3 The WoMan trial (Word catheter vs. marsu-
overlying the cyst is cleaned with Betadine
pialization), a randomized clinical trial conducted in the
The subdermal area overlying the cyst/abscess is
Netherlands in women with a Bartholin duct cyst or gland anesthetized with lidocaine, 1% to 2%, with or without
abscess, demonstrated similar recurrence rates with both epinephrine
procedures.21 The cyst/abscess wall is grasped with small forceps
Sclerotherapy using alcohol or silver nitrate may also be A 3- to 5-mm stab incision is made into the cyst wall
used to treat Bartholin duct cysts and gland abscesses.24,25 with a #11 or #15 blade
Procedure preparation is similar for fistulization or marsu- Information from references 1, 2, and 23 through 26.
pialization (Table 2).1,2,23-26 The benefits, risks, and recurrence
rates of these procedures are shown in Table 3.3,18,21,23,24,27-31
to drain. It is left in place while the tract completely epi-
FISTULIZATION thelializes, which takes approximately four to six weeks,
Word Catheter. Once the gland is drained, the Word cath- or until the balloon spontaneously expels.5 Word cathe-
eter (Figure 3 1) is placed into the defect, and the balloon is ter placement requires careful attention to incision length
inflated with 2 to 3 mL of saline (Figure 4 5;​​ also see https://​ because the catheters are often prematurely expelled.1,2,21,22
www.youtube.com/watch?v=zyopxjyExtI). The end of the A suture may be used to close the incision to help keep the
catheter is placed into the vagina while the cyst continues catheter in place.22

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 BARTHOLIN DUCT CYST
TABLE 3

Comparison of Office Procedures for Treatment of Bartholin Duct Cyst and Gland Abscess
Risk of
Procedure Benefits/advantages Risks/disadvantages recurrence

Alcohol Faster healing than silver nitrate sclero- Hyperemia;​​ hematoma;​​ tissue necro- 8% to 10% at
sclerotherapy 18,27 therapy;​​short treatment time sis;​​ scarring seven months

Incision and drain- Short treatment time High recurrence rate 13%
age alone 18,23

Jacobi ring Easy to perform;​​two drainage tracts;​​ Requires two incision sites;​​limited 0% at six months;​​
fistulization23,28 no premature expulsion;​​low cost;​​low evidence 4% at 12 months
short-term recurrence rate;​​greater
patient satisfaction compared with
Word catheter fistulization

Marsupialization 21,29,30 Low risk of recurrence Prolonged healing;​​secondary infec- 0% at six months;​​

tion;​​ prolonged external draining;​​ 10% at 12 months
greater expense

Needle aspiration18,27 Short treatment time High recurrence rate Up to 38%

Silver nitrate Less scar tissue than alcohol sclero- Scarring;​​ vulvar burning;​​ chemical 3.8% at two
sclerotherapy 24,31 therapy;​​short treatment time burns;​​ labial edema;​​ hematoma months

Word catheter Easy to perform;​​low cost;​​low short- Catheter may expel prematurely 3% at six months;​​
fistulization3,18,21 term recurrence rate (23%) if incision is too large;​​pain at 12% at 12 months
site if balloon is overinflated;​​contra-
indicated in patients with latex allergy

Information from references 3, 18, 21, 23, 24, and 27 through 31.

FIGURE 3 FIGURE 4

Word catheter

Cyst cavity

Bartholin gland

Inflated balloon
in cyst cavity

Placement of Word catheter in a patient with a Bar-

tholin duct cyst.
Inflated Word catheter. Illustration by Marcia Hartsock
Reprinted with permission from Omole F, Simmons BJ, Hacker Y. Reprinted with permission from Hill DA, Lense JJ. Office manage-
Management of Bartholin’s duct cyst and gland abscess. Am Fam ment of Bartholin gland cysts and abscesses. Am Fam Physician.
Physician. 2003;​​68(1):​​138. 1998;​​57(7):​​1613.

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 BARTHOLIN DUCT CYST

FIGURE 5

A B C

Placement of a Jacobi ring. (A) An inci-

sion is made into the mucosal surface
of the Bartholin duct abscess. Adhe-
sions are lysed, and the abscess can
drain. (B) A hemostat is tunneled into
the abscess cavity and a second inci-
sion is made. (C) The hemostat is used
to grasp one end of the Jacobi ring.
(D) The Jacobi ring is pulled through
the abscess cavity with care that the
suture is not pulled out of the cathe-
ter. (E) The two ends of the suture are
tied, forming the closed ring.
Illustrations by Dave Klemm
D E

Ring Catheter. A hemostat is passed into the abscess/cyst MARSUPIALIZATION

cavity and tunneled into the cyst and back to the vaginal
mucosa, where a second incision is made. A hemostat is
used to grasp one end of the tube/catheter, which has a piece
of suture threaded through the lumen. The suture is pulled
through the cavity along the same plane, taking care not to
pull out the catheter. The two ends of the suture are tied,
forming a closed ring (Figure 5). Placement of a ring cathe-
ter does not risk premature expulsion and has the benefit of
creating two drainage tracts.23
There are no commercially available ring catheters,
and two techniques for creating them in the office have
been described:​​(1) a 7-cm length of an 8-French T tube
is threaded with a 20-cm length of 2-0 silk suture (Jacobi
ring)23;​​or (2) a 5-cm piece of tubing from a butterfly blood
collection set is threaded with absorbable sutures (Vicryl)
through the lumen.28
The ring catheter is left in place up to four weeks to per-
mit full epithelialization. Removal is done in the physi-
cian’s office by cutting the suture, then removing the entire
tube.23,28
Marsupialization can be used for Bartholin duct cysts and
gland abscesses and is the preferred treatment for recurrent
lesions.17,31,32 An incision the entire length of the cyst wall
is made. Once the cyst is open, it is drained and irrigated
with saline. The cyst wall and mucosa are sutured open with
interrupted absorbable sutures (2-0 or 3-0 Vicryl) using a
small needle (Figure 6 1;​​ also see https://​w ww.youtube.com/
watch?v=mqNmGMv815E). Sitz baths are recommended at
least daily beginning on postoperative day 1. The patient is
evaluated four weeks after the procedure to assess resolu-
tion and adequate healing.17
SCLEROTHERAPY
Sclerotherapy, also known as ablation, is a chemical destruc-
tion of the epithelial lining of a Bartholin duct cyst or gland
abscess. A randomized controlled trial concluded that the
effectiveness and safety of alcohol vs. silver nitrate sclero-
therapy are similar despite the minor risks of tissue necrosis
and scar formation.24 Both procedures have tolerable com-
plication and recurrence rates. Alcohol sclerotherapy had a

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 BARTHOLIN DUCT CYST
SORT:​​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References Comments

Bartholin duct cysts or gland abscesses can be effec- A 1, 2, 17, 19, 21, 32 Based on consistent evidence
tively treated by several office procedures under local from patient-oriented studies
anesthesia. and supported by usual practice

Biopsy with and without excision is recommended in C 1, 5, 8 Consensus based on expert

patients 40 years and older to rule out malignancy. opinion and supported by usual
practice

Jacobi ring and Word catheter placement have accept- B 19, 23 Based on consistent evidence
able recurrence rates and low complication risks. from patient-oriented studies

Bartholin duct cysts or gland abscesses treated with inci- B 1, 2, 5, 8, 17, 18 Based on patient-oriented evi-
sion and drainage alone or with needle aspiration have a dence with small sample size
high rate of recurrence.

A = consistent, good-quality patient-oriented evidence;​​B = inconsistent or limited-quality patient-oriented evidence;​​C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://​w ww.aafp.
org/afpsort.

healing time of five days vs. 10 days for silver nitrate sclero- RECURRENCE AND EXCISION
therapy.18,24 Preparation of the vaginal mucosa for both pro- Excision is appropriate after any recurrence. Alternatively,
cedures is described in Table 2.1,2,23-26 Word catheter fistulization and marsupialization can be
Alcohol Sclerotherapy. An 18- to 20-gauge needle is used for the first recurrence. The patient should be referred
inserted into the cyst at the point of maximal fluctuation. to a gynecologist for excision if she has recurrent lesions,
The contents are aspirated until the cyst walls collapse. A has cysts larger than 5 cm, or is 40 years or older.1,5,17,33
similar volume of 70% alcohol is injected into the cyst and This article updates previous articles on this topic by Omole, et
left for five minutes, then aspirated. Healing usually occurs al.,1 and by Hill and Lense.5
within one week.18 Data Sources:​​ A PubMed search was completed using the key
Silver Nitrate Sclerotherapy. A clamp is placed into the terms Bartholin’s cyst, gland abscess, and treatment options.
cyst/abscess, and the con-
tents are fully drained. A
5-mm diameter silver nitrate FIGURE 6
stick, trimmed to a length of
5 mm, is inserted into the
cavity. One suture is applied
to the incision site to allow
retention of the stick in the
cavity and continued drain-
age. Using a clamp, the stick
is removed with the necro-
tized tissue after three days.
Healing time is approxi-
mately two weeks.18,24

PROCEDURES NOT
RECOMMENDED
Incision and drainage and
needle aspiration are sim-
ple procedures, but they
have higher recurrence
rates compared with the
previously discussed office
procedures and are not
recommended.5,8,17,18
A B
Marsupialization of a Bartholin duct cyst. (A) A vertical incision is made over the cen-
ter of the cyst to dissect it free of mucosa. (B) The cyst wall is everted and approxi-
mated to the edge of the vestibular mucosa with interrupted sutures.
Illustration by Marcia Hartsock
Reprinted with permission from Omole F, Simmons BJ, Hacker Y. Management of Bartholin’s duct cyst and
gland abscess. Am Fam Physician. 2003;​​68(1):​​139.

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 BARTHOLIN DUCT CYST
The search included meta-analyses, randomized controlled
trials, clinical trials, and reviews. We also searched the Cochrane
database and Essential Evidence Plus. References in these
resources were also searched. Search dates:​​January 2018 to
January 2019.
The Authors
FOLASHADE OMOLE, MD, FAAFP, is a professor and chair of
the Department of Family Medicine at Morehouse School of
Medicine, Atlanta, Ga.
RIBA C. KELSEY, MD, MSCR, FAAFP, is director of the Family
Medicine Residency Program and an assistant professor in
the Department of Family Medicine at Morehouse School of
Medicine.
KIWITA PHILLIPS, MD, is associate program director and
an assistant professor in the Department of Obstetrics and
Gynecology at Morehouse School of Medicine.
KIRSTIE CUNNINGHAM, MD, FACOG, is director of maternal
child health and an assistant professor at Morehouse School
of Medicine.
Address correspondence to Folashade Omole, MD, FAAFP,
Department of Family Medicine, Morehouse School of Med-
icine, 720 Westview Dr., Atlanta, GA 30310 (e-mail:​​fomole@​
msm.edu). Reprints are not available from the authors.
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Volume 99, Number 12 ◆ June 15, 2019